Provider Demographics
NPI:1417635905
Name:DOHERTY, CASEY T
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:T
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6842 MCLENNAN AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE BALBOA
Mailing Address - State:CA
Mailing Address - Zip Code:91406-4529
Mailing Address - Country:US
Mailing Address - Phone:702-539-6560
Mailing Address - Fax:
Practice Address - Street 1:18646 OXNARD ST TARZANA, CA 91356
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356
Practice Address - Country:US
Practice Address - Phone:818-996-1051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-XZYKQV175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist